Yasushi KATSUMA, Ph.D., LL.M.Waseda University

Assistant Dean & Professor, Faculty of International Research & Education;

Director, International Studies Program, Graduate School of Asia-Pacific Studies;

Director, Waseda Institute for Global Health

� In many developing countries, including those of sub-Saharan Africa, basic life-saving prevention and treatment are not readily available to large segments of the population, leading to unacceptable rates of preventable death, particularly among children under 5 and pregnant women. � The Under-5 Mortality Rate in sub-Saharan Africa is 148 per 1,000 live births, while its average in industrialized countries is 6.

� The Maternal Mortality Ratio in sub-Saharan Africa is 920 per 100,000 live births, while its average in industrialized countries is 8.

� First, the proliferation of information allows us to see the suffering of people in Africa, which has instilled in many of us a moral determination to respond to this challenge for humanity.

� Second, it has become increasingly clear that the health of one community now has serious implications for that of other communities around the world. � For example, the outbreak of the severe acute respiratory syndrome (SARS) in 2003 offers a vivid illustration of the way in which infectious diseases can travel rapidly, ignoring national borders and socio-economic differences.

� We are reminded that health threats to people on the other side of the world are our business, not only for moral reasons but also because it has the potential to affect us physically.

� Third, health threats can also have significant economic impacts.

� The impact of HIV/AIDS on development is attributable to its ability to undermine three main determinants of economic growth, namely physical, human and social capital.

� Current estimates suggest that HIV/AIDS has reduced the rate of growth of Africa’s per capita income by 0.7 percentage points a year.

� In addition, for those African countries affected by malaria, the growth rate was further lowered by 0.3 percentage points per year.

� Fourth, the antiretroviral (ARV) treatment that can extend the lives of HIV-infected people is often prohibitively expensive, so that few developing countries are able to provide these life-saving drugs to this vulnerable group without external assistance. � Once people living with HIV start taking ARV drugs, they have to continue doing so for the rest of their lives.

� If they lose their access to these drugs, not only does it mean certain death for them, but it also means the emergence of drug-resistant strains of HIV, which in turn leads to a collective cost for the rest of the world in terms of research and development searching for new drugs.

� Fifth, many of the private companies that depend on workforces and markets throughout Africa have found that their economic interests are greatly compromised, as a result of rapidly rising disease burdens. � In some parts of Africa, for example, employers have to hire and train three people for every job due to the devastation caused by HIV/AIDS, such as high death rates among employees and growing absenteeism: Employees are too ill to work, have to stay home to take care of sick family members, or have to take time off to attend funerals.

� Furthermore, private companies, carrying out large-scale building and extraction projects in areas where malaria is endemic, have found that the cumulative effect of individual employees having to take time off when they or their family members suffer from malaria can have staggering costs because of delayed production schedules.

� As these examples illustrate, improving

people’s health has become a major global

challenge, and we need to engage in

collective action to combat infectious

diseases.

� A strong international commitment to taking a human security approach to dealing with global health has the potential to contribute to improved health for all.

� First, as a “human-centered approach,” the focal point of human security is individuals and communities. � It is important that people recognize their right to health and ask for health services that they deserve.

� People’s proactive participation as the rights-holders will help strengthen the health systems that will respond more effectively to their health needs.

� Second, the human security approach highlights people’s vulnerability and tries to help them build resilience to currentand future threats. � Those who face violent conflicts or natural disasters find themselves even more vulnerable to health challenges, as their already-limited access to basic social services further deteriorates.

� Therefore, it is important to look beyond the health sector and take a multi-sectoral, comprehensive approach, in which health is seen within the context of various threats affecting people’s wellbeing.

� Third, the human security approach allows us to strengthen the interface between “protection” and “empowerment.”� The “protection” strategy, through which basic social services are provided, is of course crucial.

� Nevertheless, at the same time, the “empowerment” strategy is equally critical, so that people can take care of their own health and build their own resilience to cope with various threats.

� It is also important to look at the interface between these two strategies.

� Examples include strengthening people’s ability to act on their own to secure access to services; relying on community healthcare workers who are more embedded in the local context and more aware of the various threats to the community members; and educating and mobilizing people to focus more on the health of the community.

� In other words, it is imperative for those who have political and economic power not only to create a protective environment by providing vital services, but also to empower individuals and communities so that they can have more control over their own health, allowing them to live in dignity.

� The Okinawa Infectious Disease Initiative, launched at the G8 Summit in Kyushu & Okinawa in 2000, led to strengthened global efforts to combat several diseases, including especially HIV/AIDS, tuberculosis, and malaria, but also polio, parasitic and other neglected tropical diseases. � These efforts at the Kyushu/Okinawa G8 Summit prompted the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), as well as corresponding disease-specific programs, which is directly linked to the Goal 6 of the Millennium Development Goals (MDGs).

� The disease-specific programs have attracted substantial financial support in recent years, and have produced significant results.

� The Roll Back Malaria (RBM) initiative, launched by WHO, UNICEF, UNDP and the World Bank in 1998, has been helping strengthen public-private partnerships to reduce malaria episodes in Africa. � The goal of the RBM partnership is to halve the burden of malaria by 2010, by forming an alliance of a wide range of partners, including malaria-endemic African countries, multilateral organizations, bilateral development agencies, NGOs, foundations and private businesses, organizations of affected communities, and research & academic institutions.

� In response, in 2000, African heads of state convened a RBM Summit in Abuja in order to express their personal commitments to fight malaria.

� At the 3rd Tokyo International Conference on African Development (TICAD) in September 2003, malaria was discussed, not only as a threat to African children and women but also as an obstacle to economic development in Africa.

� It became clear that the private sector played an important role in reducing the malaria burden. � For example, the Olyset bednet, the first long-lasting insecticidal nets (LLINs) approved by WHO, was identified as an effective tool to prevent malaria.

� As a follow-up to TICAD III, the Government of Japan made a commitment to donate 10 million LLINs to Africa in five years.

� In addition, Sumitomo Chemical, the producer of the Olyset, was encouraged to transfer the technology and support the local production in Tanzania, through various public-private partnerships.

� In 2005, the United Nations Millennium Project released a report, prescribing a strategy to fight malaria. In this report, the distribution of LLINs, cutting child deaths by 20% when properly used, was highlighted as one of the Quick-Win measures.

� However, of course, the distribution of LLINs alone would not reduce the malaria burden unless there are strong health systems effectively utilizing such inputs.

� Eight years after the Kyushu/Okinawa

Summit, Japan again hosted the G8 Summit

in 2008, this time in Toyako, Hokkaido, and

global health was identified as one of the

priorities on the summit agenda.

� Japan demonstrated its commitment not only to

support global health, but to do so by taking a

human security approach: empowering

individuals to become more resilient and creating

a protective environment for them through

health system strengthening.

� The renewed attention to the health systems seems to be derived from two factors:

� First, it has become clear that the Goals 4 and 5 of the MDGs are not on track to be achieved by the year 2015, while some tremendous progress has been reported in relation to the disease-specific Goal 6. � Although annual deaths among children under five dipped below 10 million in 2006, child mortality rates remain unacceptably high.

� Similarly, the high risk of dying in pregnancy or childbirth continues unabated in many countries in sub-Saharan Africa and Southern Asia.

� Therefore, it is increasingly recognized that the Goals 4 and 5 cannot be achieved without accelerating health system strengthening.

� Second, in 2008, as we celebrated the 30th

anniversary of the 1978 Alma Ata

Declaration, the concept of primary

health care (PHC) has been revisited

and re-interpreted in the current context.

� WHO has proposed that countries should

make health systems and health development

decisions guided by four inter-linked policy

directions: universal coverage, people-

centered services, healthy public policies and

leadership.

� Hosting the G8 Summit in July 2008

provided Japan with the opportunity to

put the human security concept into

practice, and the Japanese Presidency set

up a G8 Health Experts Group.

� Building on the Saint Petersburg

commitments to fight infectious diseases, the

G8 Experts produced “Toyako Framework

for Action on Global Health,” outlining the

current situation, the principles for action,

and actions to be taken on global health.

� The principles for action on global health include the following:

� First, the G8 will continue to make efforts so that its previouscommitments will be met, including the one made at Heiligendamm in 2007, through coordinated and complementary action.

� Second, the G8 will approach the health-related MDGs in a comprehensive manner.

� Third, the human security approach, focusing on protection and empowerment of individuals and communities, will be taken in addressing global health challenges.

� Fourth, a longer-term perspective that extends beyond the 2015 deadline for the MDGs is critical in supporting research and development.

� Fifth, the effective utilization of financial and human resources requires the leadership and good governance of developing countries and the respect of their ownership consistent with the“Paris Declaration on Aid Effectiveness.”

This Declaration emphasizes ownership by partner countries, alignment

between donors and partner countries and harmonization among donors

for the purpose of managing for results and mutual accountability.

MOH MOEC

MOF

PMO

PRIVATE SECTORCIVIL SOCIETYLOCALGVT

NACP

CTU

CCAIDS

INT NGO

PEPFAR

Norad

CIDA

RNE

GTZ

SidaWB

UNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTPNCTP

HSSPHSSP

GFCCPGFCCPDAC

CCM

T-MAP

3/5

SWAPSWAP

UNTG

PRSPPRSP

Source: Mbewe, WHO.

� Among these five principles for action

outlined in “Toyako Framework for Action

on Global Health,” the second, third and

fifth principles will be discussed further in

the following sections:

� It is critical to develop a comprehensive global health framework integrating the two strategies of disease-specific programming and health system strengthening.

� In other words, we need to move beyond the debate on vertical versus horizontal programming, and look at how these two strategies can be better integrated to provide maximum benefit for health outcomes. � We are already seeing evidence of healthcare facilities and workers being freed up to focus on a broad range of health issues as a direct result of large-scale successful initiatives to prevent and treat HIV/AIDS and malaria.

� At the same time, these disease-specific targets require strong health systems delivering basic social services.

� As a result, it is no longer appropriate to look at these two strategies as separate enterprises competing for a finite set ofresources.

� Instead, we need to find ways in which they can complement each other for more efficient and effective action.

� This integration needs to be done through careful coordination among existing actors and activities, with active involvement of both donor and recipient governments, civil society and private sector stakeholders, and communities. � It is not clear, though, what institution or institutions should play this role.

� It requires a convening capacity as well as global legitimacy.

� We should strongly endorse the principle of integration, which will provide more impetus for efforts within the field of global health to promote harmonization and alignment.

� More fully integrating these strategies will require more systematic monitoring and evaluation of these efforts so that planning and implementation can be based on strong evidence of what works and what does not. � However, there are currently too many actors engaged in their own systems of monitoring and evaluation, leaving us with a confusing array of data, particularly on health systems, and imposing additional burdens on implementing agencies and recipient countries that have to spend precious time and resources on multiple evaluations.

� Therefore, we should make efforts to develop common indicators and methodologies that they will accept for monitoring and evaluating their bilateral and multilateral assistance for global health.

� Another principle for action is to take a human security approach to addressing the challenges of global health. � Although we generally talk about global health at the macro level, we should not lose track of the fact that health stronglyimpacts and is impacted by many other factors in people’s lives.

� Focusing our efforts on individuals and communities requires a human security approach, integrating protection and empowerment strategies, as health challenges cross sectors and national boundaries.

� Investing in health of our fellow human beings in the developing world will also help to protect our own citizens from health-related threats, particularly infectious diseases that travel across international boundaries easily.

� We can also anticipate significant benefits in terms of economic development and social stability emerging from healthier communities around the world.

� In order to translate the above principles into concrete action, it is necessary to mobilize more resources for global health, from both industrialized and developing countries, to respond appropriately to the overwhelming challenges.� Development assistance for health has increased from US$2.5 billion in 1990 to almost US$14 billion in 2005.

� Nevertheless, the magnitude of the challenges we face in global health is staggering, and we need additional investments for disease-specific approaches as well as for health system strengthening or a mechanism that integrates the two strategies for maximum mutual benefit.

� The dramatic increase in funding for specific infectious diseases, particularly HIV/AIDS, tuberculosis, and malaria, has led to some concern that it is distorting the healthcare sector in many countries with weak health systems. � Another way of looking at it, though, is that funding for infectious diseases has shown us what is possible when the international community makes a strong commitment to fighting specific health threats, and highlighted the areas where we have failed to make progress.

� Therefore, rather than cutting back on those efforts, the lessons that have been learned through disease-specific funding over the past five years should be applied to the health sector more broadly.

� And, we should be consistent in our message that creating more equity within the health sector does not mean reducing funding for infectious diseases, but increasing funding for other areas of the health sector that have not received as much attention.

11,45211,687

10,473 10,489 10,46610,152

9,106

8,5788,169

7,8627,597

418 347 337 330 294 295 331 296558

207 298

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Total ODA (¥100 million) Health (¥100 million)

Recipient Amount (¥1,000)

GFATM 20,646,755

UNICEF 13,426,292

WHO 4,271,946

UNFPA 4,069,910

UN Trust Fund for Human Security

(UNTFHS)

2,000,000

UNAIDS 322,756

International Planned Parenthood Federation

(IPPF)

1,476,268